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Adverse birth outcomes, including low birth weight and preterm birth, are a serious public health concern given their association with short- and long-term negative health consequences for mothers and children (Butler & Behrman, 2007). Extant evidence suggests that maternal exposure to adverse childhood experiences (ACEs) is a risk factor for adverse birth outcomes, yet few studies examine psychosocial pathways linking maternal childhood adversity to birth outcomes (e.g., Madigan et al., 2017; Racine et al., 2018). One possible pathway, financial stress (e.g., difficulty paying bills), is associated with both exposure to childhood adversity and adverse birth outcomes (Metzler et al., 2017; Mitchell & Christian, 2017). Moreover, approximately 60% of peripartum mothers report healthcare unaffordability and 54% report general financial stress during pregnancy (Taylor et al., 2021). The goal of the present study was to test whether maternal exposure to ACEs is indirectly associated with three birth outcomes (infant birth weight, gestational age, and NICU stay) through financial stress during pregnancy. We hypothesized that a higher maternal ACE score would be associated with greater financial stress during pregnancy, which would be associated with a greater likelihood of NICU stay, earlier gestational age at birth, and lower infant birth weight.
Data were obtained from a prospective cohort study of pregnant women and their infants. Mothers (n = 531; Mage = 29.8; 38% Black; 22% Hispanic ethnicity) self-reported their exposure to childhood adversity and financial stress during pregnancy. Adverse childhood experiences were assessed using the 10-item measure from the CDC-Kaiser ACE Study. Scores were summed to create a total ACE score. Financial distress was assessed using the six-item Financial Stress Index, reflecting financial stressors during the past three months. Scores were summed (range: 0-30) with higher scores indicating more financial stress. Data on infant gestational age at birth, birth weight, and admittance to the NICU (yes/no) were obtained from medical records within seven days of delivery. After examination, data were assumed to be missing at random and were handled using pairwise deletion for our binary outcome (NICU stay) and full information maximum likelihood estimation for continuous outcomes. Mediation analysis was used to test hypotheses, adjusting for study cohort, maternal race, ethnicity, body mass index, and tobacco use during pregnancy. Bootstrapped standard errors were obtained in all models using 5,000 draws, and statistical significance was set at a threshold of p < 0.05.
See Table 1 for complete results. Maternal exposure to ACEs was positively associated with financial stress during pregnancy in all three models (p’s < 0.05). Financial stress was inversely associated with gestational age at birth (p = .01) and mediated the association between maternal ACE score and infant gestational age at birth (p = .02), such that a higher maternal ACE score was associated with earlier gestational age at birth through increased financial stress during pregnancy.
Findings demonstrate one pathway linking maternal childhood adversity to a potentially preterm birth or shorter gestational age at delivery and indicate a need for targeted intervention to support expecting mothers who face financial stress.